Queen Mira International School

Aravindar Nagar, Sholavandhan Road,

Madurai - 625010, Tamil Nadu, India.
E-mail: [email protected]
Contact: +91 9655777000 or +91 9787570746 or Visit www.queenmira.com

Please complete the form clearly in block letters using BLACK ink. If you need help in completing
this form, please contact the Student Admissions Team on +91 9655777000

Office use only

Please affix
Passport Size
Photo of the
Student here

Application No.
Grade Level
Application Receipt Date
Application Status
Emergency Contact #
Data Protection Statement

The purpose for collecting your personal details on this form is to allow the QMIS Students Admission Team to process your
application. Once the form has been completed the information will be stored in hard copy and on the Students Admission Teams
electronic database. Access to the information will be on a need-to-know basis and will be archived as a part of the students
records. This information will not be shared with any other organizations or partner agencies.

STUDENT PERSONAL DEMOGRAPHY

Name

______________________

__________________

First Name

Date of Birth

____/_____/______
(dd /

Gender

Middle Name

Male

_________________________
Sur name / Initials Expanded

Age as on 1st June 2010: ____ years & ____ months

mm / yyyy )

Female

First Language

_________________________

Citizenship________________________

Place of Birth

_________________________

Religion ________________________

Blood Group

_________________________

RESIDENTIAL ADDRESS
_________________________________________________________________________________
_________________________________________________________ Pin code: _______________
Home Phone #: _______________________

Hand Phone #: _____________________________

Email to which communication to be sent : ______________________________________________

EDUCATIONAL BACKGROUND
The School in which the student is currently attending or which he / she last attended?
Name of School

City

From

To

Grade

MEDICAL INFORMATION
Has your child been vaccinated for Hepatitis B / Polio / Measles / Typhoid ?

Y/N

Does your child use corrective help for sight (glasses) or hearing?

Y/N

If yes, share details ________________________________________________

DETAILS OF THE PARENTS / GUARDIAN

Name of Father / Guardian ________________ _________________ ___________________
First Name

Citizenship

_____________

Occupation

Salaried

Middle Name

Sur name / Initials Expanded

Educational Qualification ______________________

Professional

Self-Employed

If you are a doctor, can we use your service in case of medical emergency?

Others
Y/N

What is your medical specialization ? _________________________________________________

Emergency Contact #

_________________________ (with STD codes, if applicable)

Day Time Contact #

_________________________________________________________

Name of Mother / Guardian ________________ _________________ ___________________

First Name

Citizenship

_____________

Occupation

Salaried

Middle Name

Sur name / Initials Expanded

Educational Qualification ______________________

Professional

Self-Employed

If you are a doctor, can we use your service in case of medical emergency?

Others
Y/N

What is your medical specialization? ________________________________________________

Emergency Contact #

_________________________ (with STD codes, if applicable)

Day Time Contact #

_________________________________________________________

OTHER DETAILS
Monthly Household Income

: INR _____________________

Is the applicant living with Grand parents?

:Y/N

Who will guide the student at home, if required? : _________________________

Details of siblings of the applicant attending/attended QMIS or SAM School Madurai ?

1. Name of the Sibling : ____________________________ Grade _______

Year of Admission _______

2. Name of the Sibling : ____________________________ Grade _______

Year of Admission _______

Why did you choose Queen Mira for your childs educational needs?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

PROOF & DOCUMENTS DETAILS

You are expected to include with the application form a copy of:
1. Transfer Certificate (for age 5 and above)
2. Passport
3. Last School Report
4. Birth Certificate
5. Proof of Residence
6. Community Certificate

Queen Mira International School

Aravindar Nagar, Sholavandhan Road,

Madurai - 625010, Tamil Nadu, India.
E-mail: [email protected]
Contact: +91 9655777000 or +91 9787570746 or Visit www.queenmira.com

Application Form & Declaration of Conformity

Students Name __________________________________________ Grade Applying For

_________________

Parent/Guardian please read and sign/date below:

I have truthfully and to the best of my knowledge completed the application for the above named student. I
authorize Queen Mira International School to contact past and current schools, teachers, tutors,
administrators, and other sources to obtain information to support this application. I will not seek access to
the confidential teachers evaluation materials before or after my childs admission. The undersigned
releases every person and institution from any and all liability resulting from or pertaining to the furnishing
of records, documents, and other information provided to Queen Mira International School for this purpose.
If my child is accepted for admission, I undertake to abide with the schools rules that may change from
time to time and also be governed by the Parent Student Hand Book that may change from time to time.
Queen Mira International School may use my childs photograph in school publications and promotions.
.

Signature of Parent / Guardian ___________________

Date: _______________

Signature of Student

Date: _______________

____________________

Forwarded by Students Admission Team

Signature _______________________

Admission by Chairman is

Signature _______________________

www.queenmira.com